<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <title>Title</title>
</head>
<body>
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<style type="text/css">

    /*通过控制td的padding控制tr的padding*/
    table td {
        padding: 2px;
    }

    .top-head {
        font-size: 25px;
        text-align: center;
        margin-bottom: 5px;
    }

    .my-head {
        border: none;
        margin-bottom: 6px;
        text-align: center;
        table-layout: fixed;
        word-break: break-all;
        font-size: 10px;
    }

    .my-body {
        border: none;
        border-collapse: collapse;
        text-align: center;
        table-layout: fixed;
        word-break: break-all;
        font-size: 10px;
    }

    .my-body thead tr th,
    .my-body tbody tr td {
        border: 1px solid black;
        border-collapse: collapse;
    }

    .my-foot {
        border: none;
        text-align: center;
        table-layout: fixed;
        word-break: break-all;
        font-size: 10px;
    }
</style>
<div style="width:750px; margin: 0 auto;">
    <div class="top-head">环球安化职工基本医疗保险费用结算单</div>
    <div>
        <table class="my-head" width="750" height="50" cellspacing="0" cellpadding="0" border="0">
            <tr>
                <td>结算ID</td>
                <td>34100012084040</td>
                <td>结算日期</td>
                <td>2021-10-28</td>
                <td>医疗类别</td>
                <td>普通住院</td>
            </tr>
            <tr>
                <td>医院编号</td>
                <td>H34010200168</td>
                <td>医院机构名称</td>
                <td>合肥安化创伤康复医院</td>
            </tr>
        </table>
    </div>
    <div>
        <table class="my-body" width="750" cellspacing="0" cellpadding="0" border="0">
            <tr>
                <td colspan="4">姓名</td>
                <td colspan="4">孟凡军</td>
                <td colspan="4">性别</td>
                <td colspan="4">男</td>
                <td colspan="4">个人编号</td>
                <td colspan="4">34990010306345</td>
                <td colspan="4">人员类别</td>
                <td colspan="4">在职</td>
            </tr>
            <tr>
                <td colspan="8">身份证号</td>
                <td colspan="8">340404198204010836</td>
                <td colspan="8">险种类型</td>
                <td colspan="8">职工基本医疗保险</td>
            </tr>
            <tr>
                <td colspan="4">入院日期</td>
                <td colspan="4">2021-10-14</td>
                <td colspan="4">出院日期</td>
                <td colspan="4">2021-10-28</td>
                <td colspan="4">治疗方式编码</td>
                <td colspan="4"></td>
                <td colspan="4">治疗方式名称</td>
                <td colspan="4"></td>
            </tr>
            <tr>
                <td colspan="8">出院诊断编码</td>
                <td colspan="8">84918</td>
                <td colspan="8">出院诊断名称</td>
                <td colspan="8">下肢肌肉损伤后遗症</td>
            </tr>
            <tr>
                <td colspan="8">医疗费用发生额</td>
                <td colspan="6">符合范围费用</td>
                <td colspan="6">部分自付</td>
                <td colspan="6">全额自费</td>
                <td colspan="6">超限价费用</td>
            </tr>
            <tr>
                <td colspan="8">90</td>
                <td colspan="6">90</td>
                <td colspan="6">0</td>
                <td colspan="6">0</td>
                <td colspan="6">0</td>
            </tr>
            <tr>
                <td colspan="8">实际支付起付线</td>
                <td colspan="8">90</td>
                <td colspan="8">基本医疗保险统筹基金支出</td>
                <td colspan="8">0</td>
            </tr>
            <tr>
                <td colspan="8">公务员医疗补助基金支出</td>
                <td colspan="8">0</td>
                <td colspan="8">职工大额医疗费用补助基金支出</td>
                <td colspan="8">0</td>
            </tr>
            <tr>
                <td colspan="8">居民大病保险基金支出</td>
                <td colspan="8">0</td>
                <td colspan="8">医疗救助基金支出</td>
                <td colspan="8">0</td>
            </tr>
            <tr>
                <td colspan="8">其他基金支出</td>
                <td colspan="8">0</td>
                <td colspan="8">基金支付总额</td>
                <td colspan="8">0</td>
            </tr>
            <tr>
                <td colspan="8">个人账户支出</td>
                <td colspan="8">0</td>
                <td colspan="8">个人现金支出</td>
                <td colspan="8">90</td>
            </tr>
            <tr>
                <td colspan="8">余额</td>
                <td colspan="8">0</td>
                <td colspan="8">个人负担总金额</td>
                <td colspan="8">90</td>
            </tr>
            <tr>
                <td colspan="4">序号</td>
                <td colspan="7">基金支付类型名称</td>
                <td colspan="7">基金支付金额</td>
                <td colspan="7">本次可支付限额金额</td>
                <td colspan="7">符合政策范围金额</td>
            </tr>
        </table>
    </div>
    <div>
        <table class="my-foot" width="750" height="50" cellspacing="0" cellpadding="0" border="0">
            <tr>
                <td>制表人：</td>
                <td></td>
                <td>打印日期：2021-10-28</td>
                <td></td>
                <td>医院(盖章)：</td>
                <td></td>
            </tr>
        </table>
    </div>
</div>
"
</body>
</html>